Note to reviewers: Cognitive interviews will be conducted in Spanish only. For ease of review, the questionnaire is included in both English and Spanish.
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).
Form Approved OMB #0920-0222; Expiration Date: 07/31/2018
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The first questions are about health care services you may have used in the past year. In the past year, did you go to a hospital emergency room?
(01)
YES
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In the past year, did you go to a hospital clinic or outpatient department?
(01)
YES
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Next, I want to ask about your visits to doctors in the past year.
Have
you seen a medical doctor in the past year? Please do not include
a doctor seen at home, at an emergency room or outpatient
department, or while an inpatient at a hospital.
(01)
YES
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SHOW CARD SC1 We’re
interested in how you feel about the health care you have received
over the past year from doctors and hospitals. Please tell me how
satisfied you have been with the following:
(01)
VERY SATISFIED
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SHOW
CARD SC1
(01)
VERY SATISFIED
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SHOW
CARD SC1 The ease and convenience of getting to a doctor from where you live.
(01)
VERY SATISFIED
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SHOW
CARD SC1
(01)
VERY SATISFIED
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SHOW
CARD SC1
(01)
VERY SATISFIED
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SHOW
CARD SC1
(01)
VERY SATISFIED
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Is there a particular medical person or a clinic you usually go to when you are sick or for advice about your health?
(01)
YES
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What
kind of place do you usually go to when you are sick or for advice
about your health -- is that a managed care plan or HMO center, a
clinic, a doctor's office, a hospital, or some other place?
(01)
DOCTOR'S OFFICE OR GROUP PRACTICE
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What
is the complete name of the place that you go to? WRITE NAME ON
WORKSHEET
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Is there a particular doctor you usually see at this place?
(01)
YES
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What
is the complete name of that doctor? WRITE NAME ON WORKSHEET
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SHOW
CARD US3
(01)
STRONGLY AGREE
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SHOW
CARD US3
(01)
STRONGLY AGREE
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SHOW
CARD US3
(01)
STRONGLY AGREE
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SHOW
CARD US3
(01)
STRONGLY AGREE
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SHOW
CARD
US3
(01)
STRONGLY AGREE
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SHOW
CARD US3
(01)
STRONGLY AGREE
ALL RESPONSES GO TO Q28
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[IF NO USUAL SOURCE OF CARE]
I
am going to read some reasons that people have given for not
having a usual source of health care. For each one, please tell
me whether or not it is a reason you do not have a usual place for
health care.
(01)
YES
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You recently moved into the area. [Is that a reason you do not have a usual source of health care?]
(01)
YES
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Your usual source of health care in this area is no longer available. [Is that a reason you do not have a usual source of health care?]
(01)
YES
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Why is your usual source of health care no longer available?
(01)
PREVIOUS DOCTOR RETIRED
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Thinking
about other possible reasons that people have for not having a
usual source of health, please tell me if this statement applies
to you: (01)
YES
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The places where you can receive health care are too far away. [Is that a reason you do not have a usual source of health care?]
(01)
YES
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The cost of health care is too expensive. [Is that a reason you do not have a usual source of health care?]
(01)
YES
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I would like to get a little information about your background.
Are you of Hispanic, Latino, or Spanish origin?
(01)
YES
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SHOW CARD DI1 Looking at this card, are you Mexican, Mexican American, or Chicano/Chicana, Puerto Rican, Cuban, or of another Hispanic, Latino/Latina or Spanish origin?
CHECK ALL THAT APPLY.
(01) MEXICAN/MEXICAN AMERICAN/CHICANO(A) (02) PUERTO RICAN (03) CUBAN (91)
OTHER HISPANIC, LATINO(A), OR SPANISH ORIGIN (SPECIFY
_______________) (-9) Refused
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SHOW CARD DI2 Looking at this card, what is your race?
[ASK IF NECESSARY: Are there any options from this card that you would like me to record?]
(01) AMERICAN INDIAN OR ALASKA NATIVE (02) ASIAN (03) BLACK OR AFRICAN AMERICAN (04) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (05) WHITE (-8) Don't Know (-9) Refused
IF RACE INCLUDES ASIAN, GO TO Q31. ELSE IF RACE INCLUDES NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, GO TO Q32. ELSE GO TO Q33.
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SHOW CARD DI3 Looking at this card, are you Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese or some other Asian group?
You can choose more than one group. CHECK ALL THAT APPLY.
(01) ASIAN INDIAN (02) CHINESE (03) FILIPINO (04) JAPANESE (05) KOREAN (06) VIETNAMESE (91) OTHER ASIAN GROUP (SPECIFY ________________________________________) (-8) Don't Know (-9) Refused
IF RACE AT Q30 NCLUDES NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, GO TO Q32. ELSE GO TO Q33.
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SHOW CARD DI4 Looking at this card, are you Native Hawaiian, Guamanian or Chamorro, Samoan, or some other Pacific Islander group?
You can choose more than one group. CHECK ALL THAT APPLY.
(01) NATIVE HAWAIIAN (02) GUAMANIAN OR CHAMORRO (03) SAMOAN (91) OTHER PACIFIC ISLANDER GROUP (SPECIFY _____________________________) (-8) Don't Know (-9) Refused
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Sexual Identity Question – Version A ½ of the respondents will receive Q33 Version A, and ½ of the respondents will receive Q34 version B.
SHOW CARD DI5-A
[FOR MALE RESPONDENTS] Which of the following options best represents how you think about yourself? (01) Gay (02) Not gay, that is, heterosexual (03) Bisexual (04) Something else (05) I don’t know how to answer
[FOR FEMALE RESPONENTS] Which of the following options best represents how you think about yourself? (01) Lesbian or Gay (02) Not lesbian or gay, that is, heterosexual (03) Bisexual (04) Something else (05) I don’t know how to answer
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Sexual Identity Question – Version B ½ of the respondents will receive Q33 Version A, and ½ of the respondents will receive Q34 version B. Response category (2) denotes the English translations of the Spanish version of the response category.
SHOW CARD DI5-B
[FOR MALE RESPONDENTS] Which of the following options best represents how you think about yourself? (01) Gay (02) Not gay (03) Bisexual (04) Something else (05) I don’t know how to answer
[FOR FEMALE RESPONENTS] Which of the following options best represents how you think about yourself? (01) Lesbian or Gay (02) Not lesbian or gay (03) Bisexual (04) Something else (05) I don’t know how to answer
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Probes for Q33 & Q34
Note to Interviewers How does the R interpret these questions and decide on their answer? Are there terms or words that cause any confusion? Even if there are words that they were uncertain about how did they decide which answer to give? For example, some respondents may not be sure about “straight” or “bisexual” or “transgender”. What process did they use to decide which response to give? If they said that “don’t know,” what would they want to know to be able to choose a response?
Observations:
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What sex were you assigned at birth, on your original birth certificate?
(01) FEMALE (02) MALE
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SHOW CARD DI6 Note to reviewers: Question reflects Spanish wording of the question and order of response options. How do you describe yourself as male, female, or transgender?
(01) Male (02) Female (03) Transgender (04) Do not identify as female, male, or transgender
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The next two questions are about education and income.
SHOW CARD DI7 What is the highest degree or level of school you have completed?
[IF THE SAMPLE PERSON ATTENDED SCHOOL IN A FOREIGN COUNTRY, IN AN UNGRADED SCHOOL, HOME SCHOOLING, OR UNDER OTHER UNIQUE CIRCUMSTANCES, REFER THE RESPONDENT TO THE SHOWCARD AND ASK FOR THE NEAREST EQUIVALENT.]
(01) NO SCHOOLING COMPLETED (02) NURSERY SCHOOL TO 8TH GRADE (03) 9TH-12TH GRADE, NO DIPLOMA (04) HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT) (05) VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL) (06) SOME COLLEGE, BUT NO DEGREE (07) ASSOCIATE DEGREE (08) BACHELOR'S DEGREE (09) MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE (-8) Don't Know (-9) Refused
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SHOW CARD DI8 Looking
at this card, which letter
best represents your total income before taxes during the past 12
months? Include income from jobs, Social Security, Railroad
Retirement, other retirement income, and the other sources of
income we just talked about.
(01)
A. Less than $5,000
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SHOW CARD AC1
(01)
ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
(03) CARDIOLOGY
(HEART)
(05) DERMATOLOGY (SKIN)
(07)
ENDOCRINOLOGY/METABOLISM (DIABETES,THYROID)
(08) FAMILY
PRACTICE
(09) GASTROENTEROLOGY
(10) GENERAL PRACTICE
(11)
GENERAL SURGERY
(12) GERIATRICS (ELDERLY)
(13) GYNECOLOGY -
OBSTETRICS
(14) HEMATOLOGY (BLOOD)
(15) HOSPITAL
RESIDENCE
(16) INTERNAL MEDICINE (INTERNIST)
(17)
NEPHROLOGY (KIDNEYS)
(18) NEUROLOGY
(19) NUCLEAR
MEDICINE
(20) ONCOLOGY (TUMORS, CANCER)
(21) OPHTHALMOLOGY
(EYES)
(22) ORTHOPEDICS
(24) OSTEOPATHY (DO)
(25)
OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT)
(26) PATHOLOGY
(27)
PHYS MED/REHAB
(28) PLASTIC SURGERY
(29) PROCTOLOGY
(30)
PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(32)
RADIOLOGY
(33) RHEUMATOLOGY (ARTHRITIS)
(34) THORACIC
SURGERY (CHEST)
(35) UROLOGY
(91) OTHER DR SPECIALTY
(SPECIFY ________________________________________)
(-8) Don't
Know
(-9) Refused
SHOW CARD SC1
(01)
VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04)
VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9)
Refused
SHOW CARD US3
(01)
STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY
DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9)
Refused
SHOW CARD DI1
(01) MEXICAN/MEXICAN AMERICAN/CHICANO(A)
(02) PUERTO RICAN
(03) CUBAN
(91)
OTHER HISPANIC, LATINO(A), OR SPANISH ORIGIN (SPECIFY
_______________)
(-8) Don't Know
(-9) Refused
SHOW CARD DI2
(01) AMERICAN INDIAN OR ALASKA NATIVE
(02) ASIAN
(03) BLACK OR AFRICAN AMERICAN
(04) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(05) WHITE
(-8) Don't Know
(-9) Refused
SHOW CARD DI3
(01) ASIAN INDIAN
(02) CHINESE
(03) FILIPINO
(04) JAPANESE
(05) KOREAN
(06) VIETNAMESE
(91) OTHER ASIAN GROUP (SPECIFY ________________________________________)
(-8) Don't Know
(-9) Refused
SHOW CARD DI4
(01) NATIVE HAWAIIAN
(02) GUAMANIAN OR CHAMORRO
(03) SAMOAN
(91) OTHER PACIFIC ISLANDER GROUP (SPECIFY _____________________________)
(-8) Don't Know
(-9) Refused
SHOW CARD DI5-A
[FOR MALE RESPONDENTS]
Which of the following options best represents how you think about yourself?
(01) Gay
(02) Not gay, that is, heterosexual
(03) Bisexual
(04) Something else
(05) I don’t know how to answer
[FOR FEMALE RESPONENTS]
Which of the following options best represents how you think about yourself?
(01) Lesbian or Gay
(02) Not lesbian or gay, that is, heterosexual
(03) Bisexual
(04) Something else
(05) I don’t know how to answer
SHOW CARD DI5-B
[FOR MALE RESPONDENTS]
Which of the following options best represents how you think about yourself?
(01) Gay
(02) Not gay
(03) Bisexual
(04) Something else
(05) I don’t know how to answer
[FOR FEMALE RESPONENTS]
Which of the following options best represents how you think about yourself?
(01) Lesbian or Gay
(02) Not lesbian or gay
(03) Bisexual
(04) Something else
(05) I don’t know how to answer
SHOW CARD DI6
(01) Male
(02) Female
(03) Transgender
(04) Do not identify as female, male, or transgender
SHOW CARD DI7
(01) NO SCHOOLING COMPLETED
(02) NURSERY SCHOOL TO 8TH GRADE
(03) 9TH-12TH GRADE, NO DIPLOMA
(04) HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT)
(05) VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL)
(06) SOME COLLEGE, BUT NO DEGREE
(07) ASSOCIATE DEGREE
(08) BACHELOR'S DEGREE
(09) MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE
(-8) Don't Know
(-9) Refused
SHOW CARD DI8
(01) A. Less than
$5,000
(02) B. $5,000 - 9,999
(03) C. $10,000 -
14,999
(04) D. $15,000 - 19,999
(05) E. $20,000 -
24,999
(06) F. $25,000 - 29,999
(07) G. $30,000 -
39,999
(08) H. $40,000 - 49,999
(09) I. $50,000 or
more
(-8) Don't Know
(-9) Refused
Note to reviewers: Cognitive interviews will be conducted in Spanish only. For ease of review, the questionnaire is included in English. See Attachment 1a.
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).
Form Approved OMB #0920-0222; Expiration Date: 07/31/2018
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Las siguientes preguntas son sobre servicios de cuidado de salud que usted puede haber usado durante el año pasado.
Durante el año pasado, ¿fue usted a la sala de emergencias de un hospital?
(01)
YES
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Durante el año pasado, ¿fue usted a la clínica o departamento de pacientes externos o ambulatorios de un hospital?
(01)
YES
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A continuación, quiero preguntarle sobre sus visitas a médicos en el último año.
¿Ha visto usted un médico durante el año pasado? Por favor no incluya médicos que haya visto en el hogar, en una sala de emergencia, departamento de pacientes externos o ambulatorios, o mientras era un paciente interno en un hospital. [IF NECESSARY, SAY, ‘Por favor mire la tarjeta AC1 para ver ejemplos de especialidades médicas.’]
(01)
YES
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SHOW
CARD SC1 Estamos interesados en saber qué piensa acerca de los servicios de salud que usted ha recibido durante el año pasado de los médicos y hospitales. Por favor dígame qué tan satisfecho(a) se ha sentido con lo siguiente:
La calidad general de los servicios de salud que usted ha recibido durante el año pasado.
1. MUY SATISFECHO(A) 2. SATISFECHO(A) 3. INSATISFECHO(A) 4. MUY INSATISFECHO(A) 5.
NO CORRESPONDE
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SHOW
CARD SC1
La disponibilidad de los servicios de salud en la noche y los fines de semana.
1. MUY SATISFECHO(A) 2. SATISFECHO(A) 3. INSATISFECHO(A) 4. MUY INSATISFECHO(A) 5.
NO CORRESPONDE
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SHOW
CARD SC1
La facilidad y conveniencia de llegar donde un médico desde donde usted vive.
1. MUY SATISFECHO(A) 2. SATISFECHO(A) 3. INSATISFECHO(A) 4. MUY INSATISFECHO(A) 5.
NO CORRESPONDE
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SHOW
CARD SC1
Los costos que usted paga de su propio dinero por los servicios de cuidado de salud.
1. MUY SATISFECHO(A) 2. SATISFECHO(A) 3. INSATISFECHO(A) 4. MUY INSATISFECHO(A) 5.
NO CORRESPONDE
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SHOW
CARD SC1
La información que le dan a usted sobre lo que está mal con usted.
1. MUY SATISFECHO(A) 2. SATISFECHO(A) 3. INSATISFECHO(A) 4. MUY INSATISFECHO(A) 5.
NO CORRESPONDE
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SHOW
CARD SC1
Los cuidados de seguimiento que usted recibe después de un tratamiento o cirugía inicial.
1. MUY SATISFECHO(A) 2. SATISFECHO(A) 3. INSATISFECHO(A) 4. MUY INSATISFECHO(A) 5.
NO CORRESPONDE
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¿Hay alguna persona de profesión médica o una clínica en particular a la cuál usted va habitualmente cuando está enfermo(a) o necesita consejo sobre su salud?
(01)
YES
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¿A qué tipo de lugar va habitualmente usted cuando está enfermo(a) o necesita consejo sobre su salud -- es ése un centro de un plan de cuidado administrado o HMO, una clínica, el consultorio de un médico, un hospital o algún otro lugar?
IF CLINIC, ASK: ¿Es ésta una clínica de pacientes externos o ambulatorios, o algún otro tipo de clínica? IF SOME OTHER PLACE, ASK: ¿Dónde es esto?
(1) CONSULTORIO DE UN MÉDICO O PRÁCTICA DE GRUPO (2) CLÍNICA MÉDICA (3) CENTRO DE UN PLAN DE SERVICIOS DE CUIDADO ADMINISTRADO/HMO (4) CENTRO DE SALUD DEL VECINDARIO/FAMILIAR (5) CENTRO DE CIRUGÍA INDEPENDIENTE (6) CLÍNICA RURAL DE SALUD (7) CLÍNICA DE UNA COMPAÑÍA (8) OTRA CLÍNICA (9) CENTRO DE EMERGENCIAS (10) MÉDICO VA A LA CASA DE SP (11) SALA DE EMERGENCIA DE UN HOSPITAL (12) DEPARTAMENTO DE PACIENTES EXTERNOS O AMBULATORIOS DE UN HOSPITAL/CLÍNICA (13) ESTABLECIMIENTO DE LA ADMINISTRACIÓN DE VETERANOS (V.A.). (14)
CENTRO DE SALUD MENTAL
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¿Cuál
es el nombre completo del lugar al que usted va? WRITE NAME ON
WORKSHEET
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¿Hay un médico en particular que usted ve normalmente en este lugar?
(01)
YES
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¿Cuál es el nombre completo de ese médico? WRITE NAME ON WORKSHEET
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SHOW CARD US3 Ahora le voy a leer algunas afirmaciones que algunas personas han hecho sobre el cuidado de salud de ellos. Piense sobre el cuidado de salud que usted recibe de (PROVIDER NAME FROM Q14/ PLACE NAME FROM Q12)]. Para cada afirmación, por favor dígame si usted está totalmente de acuerdo, de acuerdo, en desacuerdo, o totalmente en desacuerdo.
[(PROVIDER
NAME FROM Q14)
es /Los médicos en (PLACE
NAME FROM Q12)
son] muy cuidadoso(s) de chequear todo cuando lo examinan a
(usted/él/ella).
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SHOW CARD US3 [(PROVIDER NAME FROM Q14) es /Los médicos en (PLACE NAME FROM Q12) son] competente(s) y bien capacitados.
(01)
TOTALMENTE DE ACUERDO
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SHOW
CARD US3
(01)
TOTALMENTE DE ACUERDO
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SHOW
CARD US3
(01)
TOTALMENTE DE ACUERDO
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SHOW
CARD
US3
[(PROVIDER NAME FROM Q14)/Los médicos en ((PLACE NAME FROM Q12)] no le explica(n) a (usted/él/ella) sus problemas médicos.
(01)
TOTALMENTE DE ACUERDO
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SHOW
CARD US3
(01)
TOTALMENTE DE ACUERDO
ALL RESPONSES GO TO Q28
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[IF NO USUAL SOURCE OF CARE]
Le voy a leer algunas razones que las personas han dado para no tener una fuente habitual para cuidado de salud. Para cada una, por favor dígame si esta es o no una razón por la cual usted no tiene un lugar habitual para cuidado de salud.
No hay razón para tener una fuente habitual de cuidado de salud porque usted rara vez o nunca se enferma. [¿Es esa una razón por la cual usted no tiene una fuente habitual de cuidado de salud?]
(01)
YES
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Usted se mudó recientemente al área. [¿Es esa una razón por la cual usted no tiene una fuente habitual de cuidado de salud?]
(01)
YES
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Su fuente habitual de cuidado de salud ya no está disponible en esta área. [¿Es esa una razón por la cual usted no tiene una fuente habitual de cuidado de salud?]
(01)
YES
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¿Por qué su fuente habitual de cuidado de salud ya no está disponible?
(01) MÉDICO ANTERIOR SE RETIRÓ (02) MÉDICO ANTERIOR FALLECIÓ (03) MÉDICO ANTERIOR SE MUDÓ (04) SP SE MUDÓ (05)
MÉDICO/LUGAR ANTERIOR ES MUY LEJOS
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Pensando sobre otras posibles razones que las personas tienen para no tener una fuente habitual de cuidado de salud, por favor dígame si esta afirmación es válida para usted:
A usted le gusta ir a diferentes lugares para diferentes necesidades de salud. [¿Es esa una razón por la cual usted no tiene una fuente habitual de cuidado de salud?]
(01)
YES
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Los lugares en que usted puede recibir cuidados de salud están muy lejos. [¿Es esa una razón por la cual usted no tiene una fuente habitual de cuidado de salud?]
(01)
YES
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El costo del cuidado de salud es muy caro. [¿Es esa una razón por la cual usted no tiene una fuente habitual de cuidado de salud?]
(01)
YES
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Me gustaría obtener un poco de información general acerca de usted.
¿Es usted de origen hispano, latino o español?
(01)
YES
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SHOW CARD DI1 Mire esta tarjeta. ¿Es usted mexicano(a), mexicano(a) americano(a) o chicano(a), puertorriqueño(a), cubano(a) o de otro origen hispano, latino o español?
(01)
MEXICAN/MEXICAN AMERICAN/CHICANO(A)
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SHOW
CARD DI2
[EXPLAIN IF NECESSARY: Para esta encuesta, los orígenes hispanos no son una raza.]
(01)
AMERICAN INDIAN OR ALASKA NATIVE
IF RACE INCLUDES ASIAN, GO TO Q31. IF RACE INCLUDES NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, GO TO Q32. ELSE GO TO Q33.
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SHOW CARD DI3 Mire esta tarjeta. ¿Es usted hindú, chino(a), filipino(a), japonés, coreano(a), vietnamita o de otro origen asiático?
Puede seleccionar más de un grupo. CHECK ALL THAT APPLY
IF RACE AT Q30 INCLUDES NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, GO TO Q32. ELSE GO TO Q33.
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SHOW
CARD DI4
Puede seleccionar más de un grupo. CHECK ALL THAT APPLY. (01)
NATIVE HAWAIIAN (-8)
Don't Know
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Sexual Identity Question – Version A ½ of the respondents will receive Q33 Version A, and ½ of the respondents will receive Q34 version B.
SHOW CARD DI5-A
[PARA HOMBRES PARTICIPANTES] ¿Cuál de las siguientes opciones representa mejor su manera de pensar en sí mismo? (01) Gay (02) No gay, o sea, heterosexual (03) Bisexual (04) Otra cosa (05) No sé la respuesta
[PARA MUJERES PARTICIPANTES] ¿Cuál de las siguientes opciones representa mejor su manera de pensar en sí misma? (01) Gay (02) No gay o lesbiana, o sea, heterosexual (03) Bisexual (04) Otra cosa (05) No sé la respuesta
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Sexual Identity Question – Version A ½ of the respondents will receive Q33 Version A, and ½ of the respondents will receive Q34 version B.
SHOW CARD DI5-B
[PARA HOMBRES PARTICIPANTES] ¿Cuál de las siguientes opciones representa mejor su manera de pensar en sí mismo? (01) Gay (02) No gay (03) Bisexual (04) Otra cosa (05) No sé la respuesta
[PARA MUJERES PARTICIPANTES] ¿Cuál de las siguientes opciones representa mejor su manera de pensar en sí misma? (01) Gay (02) No gay o lesbiana, (03) Bisexual (04) Otra cosa
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Probes for Q33 & 34
• ¿En qué pensó cuando le hice esta pregunta? o Me puede dar un ejemplo?
• ¿En qué pensó para decidir qué contestar? o Me puede dar un ejemplo?
• ¿Cómo decidió dar esa respuesta? o ¿Podría contarme un poco más sobre eso?
• ¿Tuvo algún problema para decidir qué contestar? o If YES, ¿Qué le preocupaba?
• ¿Hubo alguna palabra de la que no estuvo seguro(a)? o ¿Cuáles? o ¿Cómo influyó eso en su respuesta?
• ¿Qué quiere decir [bisexual] para usted?
Note to Interviewers How does the R interpret these questions and decide on their answer? Are there terms or words that cause any confusion? Even if there are words that they were uncertain about how did they decide which answer to give? For example, some respondents may not be sure about “straight” or “bisexual” or “transgender”. What process did they use to decide which response to give? If they said that “don’t know,” what would they want to know to be able to choose a response?
Observations:
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¿Qué sexo le asignaron al nacer, en su acta de nacimiento original?
(01) Mujer (02) Hombre
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SHOW CARD DI6 ¿Se describe a sí mismo(a) como hombre, mujer o transgénero?
(01) Hombre (02) Mujer (03) Transgénero (04) No me identifico como mujer, hombre ni transgénero
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Las dos siguientes preguntas son acerca de educación e ingresos.
SHOW CARD DI7 ¿Cuál es el grado o nivel de escuela más alto que usted ha completado?
1. NO TIENE ESTUDIOS 2. PREESCOLAR A 8º. GRADO 3. 9º -12º GRADO, SIN DIPLOMA 4. GRADUADO(A) DE HIGH SCHOOL (CON DIPLOMA DE HIGH SCHOOL O SU EQUIVALENTE) 5. VOCACIONAL/TÉCNICO/DE NEGOCIOS/CERTIFICADO O DIPLOMA DE ESCUELA DE OFICIOS (MÁS ALLÁ DEL NIVEL DE HIGH SCHOOL) 6. ALGO DE COLLEGE O UNIVERSIDAD, PERO SIN DIPLOMA 7. GRADUADO DE UNIVERSIDAD DE 2 AÑOS CON GRADO DE ASOCIADO 8. GRADUADO DE UNIVERSIDAD DE 4 AÑOS CON GRADO DE BACHILLERATO 9. MAESTRÍA, TÍTULO PROFESIONAL O DOCTORAL 10. DON’T KNOW 11. REFUSED
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SHOW
CARD DI8
Incluya ingresos de empleos, Seguro Social, Retiro de Ferroviarios, otro ingreso de retiro, y de las otras fuentes de ingreso de las cuales acabamos de hablar.
[EXPLAIN IF NECESSARY:] El ingreso es importante para analizar la información que recolectamos. Por ejemplo, esta información nos ayuda a saber si las personas de un grupo de ingreso determinado usa cierto tipo de servicios de cuidado médico o tienen ciertas condiciones médicas más o menos frecuentemente que las personas de otros grupos.
(01)
A. Less than $5,000
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SHOW CARDS
SHOW CARD AC1
1. ALERGIA/INMUNOLOGÍA
2. ANESTESIOLOGÍA
3. CARDIOLOGIA (CORAZÓN)
5. DERMATOLOGÍA (PIEL)
6. MÉDICO DE SALA DE EMERGENCIA
7. ENDOCRINOLOGÍA/METABOLISMO (DIABETES, TIROIDE)
8. PRÁCTICA FAMILIAR
9. GASTROENTEROLOGÍA
10. PRÁCTICA GENERAL
11. CIRUGÍA GENERAL
12. GERIATRÍA (ENVEJECIENTES)
13. GINECOLOGÍA - OBSTETRICIA
14. HEMATOLOGÍA (SANGRE)
15. RESIDENCIA EN HOSPITAL
16. MEDICINA INTERNA (INTERNISTA)
17. NEFROLOGÍA (RIÑONES)
18. NEUROLOGÍA
19. MEDICINA NUCLEAR
20. ONCOLOGÍA (TUMORES, CÁNCER)
21. OFTALMOLOGÍA (OJOS)
22. ORTOPEDIA
24. OSTEOPATÍA
25. OTORRINOLARINGOLOGÍA
26. PATOLOGÍA
27. FISIOLOGÍA/REHABILITACIÓN
28. CIRUGÍA PLÁSTICA
29. PROCTOLOGÍA
30. PSIQUIATRÍA/PSIQUIATRA
31. PULMONAR (PULMONES)
32. RADIOLOGÍA
33. REUMATOLOGÍA (ARTRITIS)
34. CIRUGÍA DEL TÓRAX (PECHO)
35. UROLOGÍA
36. OTRA ESPECIALIDAD MÉDICA
(91) OTHER DR SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
SHOW
CARD SC1
1.
MUY SATISFECHO(A)
2. SATISFECHO(A)
3. INSATISFECHO(A)
4. MUY INSATISFECHO(A)
5.
NO CORRESPONDE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01)
TOTALMENTE DE ACUERDO
(02) DE ACUERDO
(03) EN
DESACUERDO
(04) TOTALMENTE EN DESACUERDO
(05) NO
CORRESPONDE
(-8) Don't Know
(-9) Refused
SHOW CARD DI1
(01)
MEXICAN/MEXICAN AMERICAN/CHICANO(A)
(02) PUERTO RICAN
(03)
CUBAN
(91) OTHER HISPANIC, LATINO(A), OR SPANISH ORIGIN (SPECIFY
_______________)
(-8) Don't Know
(-9) Refused
SHOW CARD
DI2
(01) AMERICAN INDIAN OR ALASKA
NATIVE
(02) ASIAN
(03) BLACK OR AFRICAN AMERICAN
(04)
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(05) WHITE
(-8)
Don't Know
(-9) Refused
SHOW CARD DI3
(01)
ASIAN INDIAN
(02) CHINESE
(03) FILIPINO
(04)
JAPANESE
(05) KOREAN
(06) VIETNAMESE
(91) OTHER ASIAN
GROUP (SPECIFY ________________________________________)
(-8)
Don't Know
(-9) Refused
SHOW
CARD DI4
(01) NATIVE
HAWAIIAN
(02) GUAMANIAN OR CHAMORRO
(03) SAMOAN
(91)
OTHER PACIFIC ISLANDER GROUP (SPECIFY _____________________________)
(-8)
Don't Know
(-9) Refused
SHOW CARD DI5-A
[PARA HOMBRES PARTICIPANTES]
(01) Gay
(02) No gay, o sea, heterosexual
(03) Bisexual
(04) Otra cosa
(05) No sé la respuesta
[PARA MUJERES PARTICIPANTES]
(01) Gay
(02) No gay o lesbiana, o sea, heterosexual
(03) Bisexual
(04) Otra cosa
(05) No sé la respuesta
SHOW CARD DI5-B
[PARA HOMBRES PARTICIPANTES]
(01) Gay
(02) No gay
(03) Bisexual
(04) Otra cosa
(05) No sé la respuesta
[PARA MUJERES PARTICIPANTES]
(01) Gay
(02) No gay o lesbiana,
(03) Bisexual
(04) Otra cosa
SHOW CARD DI6
(01) Hombre
(02) Mujer
(03) Transgénero
(04) No me identifico como mujer, hombre ni transgénero
SHOW CARD DI7
1. NO TIENE ESTUDIOS
2. PREESCOLAR A 8º. GRADO
3. 9º -12º GRADO, SIN DIPLOMA
4. GRADUADO(A) DE HIGH SCHOOL (CON DIPLOMA DE HIGH SCHOOL O SU EQUIVALENTE)
5. VOCACIONAL/TÉCNICO/DE NEGOCIOS/CERTIFICADO O DIPLOMA DE ESCUELA DE OFICIOS (MÁS ALLÁ DEL NIVEL DE HIGH SCHOOL)
6. ALGO DE COLLEGE O UNIVERSIDAD, PERO SIN DIPLOMA
7. GRADUADO DE UNIVERSIDAD DE 2 AÑOS CON GRADO DE ASOCIADO
8. GRADUADO DE UNIVERSIDAD DE 4 AÑOS CON GRADO DE BACHILLERATO
9. MAESTRÍA, TÍTULO PROFESIONAL O DOCTORAL
10. DON’T KNOW
11. REFUSED
SHOW CARD DI8
(01) A. Less than
$5,000
(02) B. $5,000 - 9,999
(03) C. $10,000 -
14,999
(04) D. $15,000 - 19,999
(05) E. $20,000 -
24,999
(06) F. $25,000 - 29,999
(07) G. $30,000 -
39,999
(08) H. $40,000 - 49,999
(09) I. $50,000 or
more
(-8) Don't Know
(-9) Refused
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dunston, Sheba King (CDC/OPHSS/NCHS) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |